Health Screening

Alcohol

How often did you have a drink containing alcohol, even beer or wine, in the past year?

1 Time

2 - 4 Times

4 - 8 Times

8+ Times

How many drinks do you have on a typical day when you drink?

1 Drink

2 - 3 Drinks

4 - 6 Drinks

7+ Drinks

How often did you have 5 (for men) 4 (women) or more drinks on one occasion in the past year?

1 Time

2 - 3 Times

3 - 4 Times

5 + Times

Has anyone else ever thought you might have a problem with alcohol?

Yes

No

Have you or someone else ever been injured as a result of your drinking?

Yes

No

Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?

Yes

No

Prescription Medication Misuse

Have you ever taken prescription medication that was not prescribed for you?

Yes

No

Have you ever taken prescription medication in a way that was not prescribed?

Yes

No

Have you ever taken prescription medication only for the feeling or experience that it caused?

Yes

No

Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?

Yes

No

Drugs

Have you ever used drugs such as marijuana, heroin, cocaine, PCP, LSD, methamphetamine, ecstasy?

Yes

No

Which have you used in the past 3 months?

How much are you using per day? When did you last use?

Have you ever used any drugs by injection?

Yes

No

Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?

Yes

No

Score

** Based on your responses to the questions above, a + screen to any of the above questions may indicate the need for a more comprehensive assessment to help determine if you or someone you care about may have a Alcohol, Prescription or Drug abuse problem. Please feel free to contact our nearest Outpatient location to schedule an evaluation. All information is confidential and protected by HIPAA and Federal confidentiality laws